Dr. Van Swol appropriately highlights the importance of valid, reliable assessment of health care quality as the foundation of pay-for-performance programs. He asserts that this can be achieved only through a universal electronic health record and points out the disproportionate burden of implementation in solo and rural primary health care practice settings. While I agree with Dr. Van Swol on many points, it is important to note that the overall uptake of this technology is very poor (1) and that the types and interoperability of electronic health records being implemented vary greatly (2). Data variability and consistency across different sites are, and will continue to be, very problematic and could threaten performance monitoring and pay-for-performance programs in the very health care delivery settings in which these programs could have the greatest positive impact. While legislation is being developed to provide financial incentives to implement electronic health records (3), methods for valid quality measurement that are independent of electronic health records are urgently needed. The basic science of quality measurement needs to advance to keep pace with policy reforms, and we need to create broad, clinically meaningful measures of health care quality. For example, we need to assess whether claims-based data supplemented with limited clinical data collection or patient surveys could provide acceptable data for performance monitoring purposes at the group or hospital level in the short term. The National Institutes of Health and the Agency for Healthcare Research and Quality have great potential for influence in this area. With advances in the science of quality measurement, the hope is that nascent, quality-based purchasing reforms do not stall or, worse, do not undergo a backlash similar to that of managed care reforms in the last decade.